Attachment_5_Past_Experience_Questionnaire_1622755364278.doc

PAST EXPERIENCE QUESTIONNAIRE

Your Company Name:

Street Address:

City, State and ZIP Code:

1. GENERAL BUSINESS INFORMATION

Date Firm Organized/Established:

Company President:

Vice President:

Dun & Bradstreet Number:

Is company a ; Partnership [ ] Separate entity [ ] Division [ ] N/A [ ]

2. CONTRACTS/SUBCONTRACTS COMPLETED OR IN PROGRESS

Does company have GSA contract? Yes / No

If so GSA contract(s) number:_________________________________________________

Is product offered on schedule? Yes / No Complete and submit the information requested on the next pages 2-4 below on prime contracts or subcontracts completed or in progress. Government contracts are preferred; but, if you have not performed Government contracts, indicate any other contracts completed or in progress.

a. First Contract:

Contracting Agency or Company:

Point of Contact:

Telephone Number:

Contract Number:

Contract/Subcontract Amount: $

Project/Product Title and Delivery Location:

General Scope of Project:

Your Role (Prime [ ], Joint Venture [ ], or Subcontractor [ ]) and the work your firm performed:

Describe any Work You Subcontracted to Others:

Total Amount of Subcontract(s): $

Period of Performance/Delivery Days: days Scheduled Completion/Delivery Date:

Actual Completion/Delivery Date:____

Were You Terminated?

Did you use a Quality Control Plan? _________ Did you use a Safety Plan?_______________ Delivery, Quality Control or Safety Problems encountered (if any):

How were the problems resolved?

b. Second Contract:

Your Role (Prime [ ], Joint Venture [ ], or Subcontractor [ ]) and the work your firm performed:

c. Third Contract:

Your Role (Prime [ ], Joint Venture [ ], or Subcontractor [ ]) and the work your firm performed:

4. Certification of Past and Present Performance Information:

Type or Print Information

Name of Survey Preparer _______________________________

Phone:_________________ Email:______________________

Title__________________________________________

Signature______________________________________

Date__________________________________________